Page 91 - ar2010

Clinical Governance is defned as “A framework through which the organization is accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will fourish”. The Group is fully committed to continuously enhance clinical governance as the main thrust for improving the quality of care, ensuring patient safety and capacity to maintain high standards and credibility.

At the individual hospital level, the Hospital Clinical Governance Committee (HCGC) under the chairmanship of the hospital’s Medical Director facilitates the implementation and oversees compliance to clinical governance through various clinical sub-committees such as the Hospital Medical Advisory, Credentialing & Privileging, Audit & Medical Education, Infection Control, Medical Records, Mortality Review, Pharmacy & Therapeutics and Surgical Medical Intervention Committees besides participation in other hospital management committees.

At the Group level, the Group Medical Advisory Committee (MAC) strategically plans, initiates and monitors clinical governance activities throughout the Group.

KPJ MAC governs and functions through a number of specific functional committees, namely the Clinical Governance Policy Committee (CGPC), Clinical Governance Action Committee (CGAC), Clinical Risk Management Committee (CRM), Central Credentialing & Privileging Committee (CCPC) and Central Mortality Review Committee (CMRC).

It is evident that the practice of medicine in the present days has become more challenging. The challenges are not confned to clinical issues only but often involve complex ethical, cultural and religious considerations. There is no standard or formal or structured process in dealing with these issues. Approaches are usually informal. As the breadth and depth of clinical ethic issues increases, it is necessary to have a more structured approach to handling these complex issues balancing the needs of all concerns.

KPJ MAC has therefore formed the Clinical Ethics Committee which will embark on developing services in this area. This Committee is chaired by Dato’ Dr Zaki Morad, Consultant Nephrologist from KPJ Ampang Puteri Specialist Hospital.

In general, clinical ethics refer to the activity or the discipline of identifying, analysing and resolving ethical issues arising from patient care that usually give rise to conflict amongst parties concern. The goals of clinical ethics service are to assist the doctor, the patient, family and the hospital management to resolve ethical issues with the outcome being the best interests of the patient.

In 2008, KPJ embarked on putting into operation the Seven Patient Safety Goals (Table 3) proposed by World Health Organization’s World Alliance for Patient Safety in all of the Group’s hospitals and in 2010 all the KPJ hospitals have implemented these goals successfully.

Since 2001 KPJ has been collecting and monitoring clinical data as part of our quality improvement efforts i.e. to monitor and benchmark the level of care in accordance to international or national accepted standards. This ‘Clinical Indicator Program’ is based on the National Indicator Approach developed by the Ministry of Health of Malaysia and at present KPJ now collects data and monitors sixteen parameters (Table 4).

In 2010 the Research & Development Committee chaired by Dato’ Dr Azizi Hj Omar, Medical Director & Consultant Paediatrician of KPJ Damansara Specialist Hospital was revived and four requests for permission to conduct research have been approved. The Committee identifed research in safety and quality as the main thrust into our renewed interest in research and development for the Group and this was unmistakably evident looking at the articles published in the 4th volume of the KPJ Medical Journal January 2010.

Other then developing policies and guidelines for the best practice in the interest of safe and quality care for the patients, MAC also monitors the clinical performance for the Group through monitoring of: • Patient safety indicators • Incidents • Sentinel events • Mortality cases • ADR

• Infection control • Privileging of Clinician

All clinical governance activities are reported to the Board via MAC.